Hey, why does everyone hate nurse practitioners?

[brightness]

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Hi all,
I've gone back and forth between being a physician, an NP, or a psychologist. In my looking through these forums, I've noticed a major negative view of NPs, and I wonder why. I looked at being an NP instead of a PA because I am also interested in teaching nursing students and working at a clinic for the underserved. I also would like to take some time off to get experience, because I don't have any experience yet in the medical field, and I thought nursing for a few years would be a good way to do that. If I became a midlevel I would want doctor supervision, in the clinic where I work, all the time, with the possibility of collaboration. I care for people and want to practice medicine- or advanced practice nursing, if it makes you happy- and I'd also like to go into management or even case work, all of which are available in nursing. I love the breadth and the opportunities in this field and I have no interest in surgery. Given my situation, I think I would rather pursue nursing than be a PA, but it seems that everyone on SDN has a mad hate for NPs because they aren't trained on the "medical model". I would find this to be problematic only if outcomes were worse for patients treated by PAs...I don't believe this is the case. The only reason I can think of is that NPs are able to practice independently and even own clinics, something that PAs cannot do- are MDs/DOs simply threatened by NPs? I don't think there is any replacement for a doctor, and even if I pursued a DNP for my own satisfaction, I would see myself as a midlevel provider.
What gives?

 

[psychofur]

It is all about fear. As a doc I can tell you I see this every day with other docs. It is sad insecurity.

 

[Dr_Feelgood]

It is all about fear. As a doc I can tell you I see this every day with other docs. It is sad insecurity.

Or it could be fear for the patient not the pride? We look for quick answers to problems in America. With a physician shortage and the skyrocketing cost of health care, other professions have stepped up or been created to fill the void (including my own, DPM). This can be good and bad; depending on the direction the profession goes (i.e. DPMs working more w/ diabetics on a regular basis - decreases LE wounds and amputaitons and relieves the load of other physicians; so I say good. DCs who want to be listed as PCP b/c spinal manipulation can help a patient naturally heal - bad EBM and does not help with the problems; so I say bad).

So far the system has being do well but since CRNA and AAs have gained more autonomy(in some states), many over midlevel (NPs and PAs) have looked to do the same. You must also factor in money. Equal work does not mean equal pay. So if midlevel practitioners want to increase repayment, they must find a way to break away from physicians.SO, this is where the fear factor comes in.

I think that everyone will agree that in classroom education is only step 1 in the education of a health care clinician. A midlevel clinician only will get less classroom time and clinical exposure than a doctor, even a DNP. This exposure and education is what you rely on when the brown stuff hits the fan. That is where doctors really earn their keep is when things don't go well.

So I think it boils down to what is best for the patient. You can have a bunch of DNPs say they got studies by the AANP (which I'm sure would never be biased just like those that Pfizer does on of the drugs they release) and the MD/DO can say that their profession is under attack (but their leadership created the current situation due to greed and shortsightedness). I don't have the answer but in theory (like communism) the managed care formula should work with the midlevels staying put.

 

[hunnybee24]

Well, from what I read here, many people are extremely biased towards physician assistants. If you want the nursing perspective, since many NPs do not post here, go to www.allnurses.com. It has a lot of information. I would shadow some too, but you probably already know that.

Good luck with whatever you decide to do!

🙂

 

[deleted6669]

to the o.p.- fyi-
p.a.'s in most states CAN own clinics and hire physicians to do whatever their states require in terms of supervision. in some states it might mean they hire a doc to be there all the time while the pa sees pts, in other states it might mean 10% chart review within 1 month(no onsite md presence at all), while in other states it might mean a documented meeting every 6 months for 30 min to discuss the practice(no chart review or on site md presence at all).
I have several friends who are pa's who own their own clinics in rural, inner city, and suburban locations so I can assure you it is done more often than you think.
the real advantage of pa over np is the ability to change specialty without going back to school.
the real advantage of np over pa is practicing completely independently in the 9 or so states that allow this. many states do require a "collaborating" physician so these np's are truly not independent. other states require a collaborating md if the np desires to write for controlled substances.
it is only 9 or states in which an np can hang their own shingle and work completely independently of an md and have full rx rights.( correct me if I am off on the # here if someone knows the exact # of fully independent np states).

 

[corpsmanUP]

Ultimately I see the "medical model" versus "nursing model" being judged by the courts. There will inevitably be a backlash by the public and the physician community when it is finally decided that NP's have too much autonomy. And when that is decided, it will be hard for the nurses to stand in front of the black robes and state that they practice anything outside of medicine. I mean tell me one treatment for any disease process treated by NP's that is treated ANY differently than the way a physician would treat it. There is no such thing as "advanced nursing". By definition, nursing is a subordinate role in medicine, though a very important one. It is oxymoronic to state that there is any form of advanced subordinate role. This would require supervision, which NP's are seeming to claim they do not need. Ultimately the physicians will not tolerate the turf trampelling and NP's will either be forced to practice the way PA's do in all states, or they will get the fight of their lives. Nursing lobby is powerful, but when all the physician groups lobby together for something, they have power too.

 

[brightness]

corpsman, I disagree. The nursing lobby is huge, and I'm not so sure the AMA will be able to put a stop to things so easily. I do think that nurse practitioners and advanced practice nursing is going to have to decide how they fit into medicine, as at that point I think they are far removed from being "nursing". However, I don't think that saying 'you're not medicine, you're done'...or that sort of attitude, is really going to hold out. Just my opinion.
emedpa- I really don't mind supervision, I'd prefer it. I just thought that maybe the (perhaps incorrect) assumption that NPs are less supervised than PAs might be a reason why MDs/DOs view NPs less favorably. I personally think that midlevels will "take over" a good deal of primary care, leaving physicians to oversee and also to have higher, more specialized roles in medicine. It is my opinion that, as long as patient outcomes remain good, there isn't anything wrong with this change- its just a change in the way things operate. Sometimes change happens...to the advantage of disadvantage of various groups. So, I dunno.
Dr. Feelgood- I see some of your points I agree that doctors are the best people to rely on when poo hits that fan. This is why as a midlevel, I'd have a doctor on staff, all the time. I also have no problem with paying a small malpractice insurance, as long as compensation increases- because I do see a problem with having 'indepedent' midlevels be covered under physicians malpractice. At the same time, don't overseeing physicians make money off the midlevels they supervise? Certainly that makes a difference.

As I said, if I do become a midlevel, I want physician oversight. So, I want a doctor on hand. As a midlevel- NP or PA- I am never going to think I'm as knowledgeable as a physician. Specifically, I am interested in working with rural/urban populations and I want to work with pediatrics and women's health. I want to work with people not only to deliver medical care, but also to help people deal with developmental issues and to teach them about child development, in addition to helping them locate resources within their community. From my standpoint, a focus on children and women seems to be more accessible as an NP. Also, I don't really care whether I'm an MD, DO, NP, or PA, as long as I can reach these occupational goals. SO, in addition to addressing the question I posed, I would LOVE opinions about my career goals and what might be the best way to reach them.

 

[Dr_Feelgood]

Dr. Feelgood- I see some of your points I agree that doctors are the best people to rely on when poo hits that fan. This is why as a midlevel, I'd have a doctor on staff, all the time. I also have no problem with paying a small malpractice insurance, as long as compensation increases- because I do see a problem with having 'indepedent' midlevels be covered under physicians malpractice. At the same time, don't overseeing physicians make money off the midlevels they supervise? Certainly that makes a difference.

As for the malpractice, you mention that having independent midlevels covered under physician malpractice. If you look at it from an actuary's position, it is similar to having a teenager drive. Less training and less experience means higher premiums. This may not come to be b/c when people sue midlevels that don't go for blood. I mentioned this in another thread, 1 in 12 physician malpractice amounts are over 1 million; PAs has there first 1 million suit last year.

As I said, if I do become a midlevel, I want physician oversight. So, I want a doctor on hand. As a midlevel- NP or PA- I am never going to think I'm as knowledgeable as a physician. Specifically, I am interested in working with rural/urban populations and I want to work with pediatrics and women's health. I want to work with people not only to deliver medical care, but also to help people deal with developmental issues and to teach them about child development, in addition to helping them locate resources within their community. From my standpoint, a focus on children and women seems to be more accessible as an NP. Also, I don't really care whether I'm an MD, DO, NP, or PA, as long as I can reach these occupational goals. SO, in addition to addressing the question I posed, I would LOVE opinions about my career goals and what might be the best way to reach them.

This is tough. You've got to go with your heart. It is easy to say MD/DO, but it is long and hard. The midlevel route means you are done and practicing long before the MD even gets into residency. But there is a ceiling on advancement as a midlevel.

 

[polygonal]

This has been discussed many times. There is a large difference in the philosophy and education between the two. PAs generally work with physicians; advanced practice nurses are trying to replace physicians ("separate but equal").

 

[brightness]

Ugh. I just don't know what to do. I know what my goals are, but I don't what to do. Part of me says to go ahead and be an MD/DO, but I am just not sure if I can cut it in the coursework! I'm so nervous about it...I keep thinking I want to be a doctor and then I get intimidated by the path and decide not to do it. On the other hand, being a midlevel would cause less debt, and be a shorter course.

 

[Dr_Feelgood]

Ugh. I just don't know what to do. I know what my goals are, but I don't what to do. Part of me says to go ahead and be an MD/DO, but I am just not sure if I can cut it in the coursework! I'm so nervous about it...I keep thinking I want to be a doctor and then I get intimidated by the path and decide not to do it. On the other hand, being a midlevel would cause less debt, and be a shorter course.

Have you taken the MCAT? While it does not tell you if you can handle the course load it does tell you if you are smart enough to cut it. It may help with the intimidation.

 

[bkpa2med]

Have you taken the MCAT? While it does not tell you if you can handle the course load it does tell you if you are smart enough to cut it. It may help with the intimidation.

I agree 100%.

 

[jonwill]

Have you taken the MCAT? While it does not tell you if you can handle the course load it does tell you if you are smart enough to cut it. It may help with the intimidation.

Good advice. If you take the MCAT and do well, then there is a decision to make. If you don't do well, the decision is made for you.

 

[brightness]

I haven't even taken Chem 1 yet...so my guess is, I won't do very well. I was going to be a psychologist, but then I decided that I wanted to work in health instead of mental health, basically. So now I am sort of changing my path. I guess it is a good idea, still, to take the MCAT and see if I should apply.

 

[core0]

I haven't even taken Chem 1 yet...so my guess is, I won't do very well. I was going to be a psychologist, but then I decided that I wanted to work in health instead of mental health, basically. So now I am sort of changing my path. I guess it is a good idea, still, to take the MCAT and see if I should apply.

GRE wouldn't hurt also. A lot of PA programs reqiure it.

David Carpenter, PA-C

 

[schutzhund]

Ugh. I just don't know what to do. I know what my goals are, but I don't what to do. Part of me says to go ahead and be an MD/DO, but I am just not sure if I can cut it in the coursework! I'm so nervous about it...I keep thinking I want to be a doctor and then I get intimidated by the path and decide not to do it. On the other hand, being a midlevel would cause less debt, and be a shorter course.

Look, if you want to be doctor, go for it! You won't cut the coursework if you don't try. I know it seems intimidating but if you want it you can get it.

Trust me, I know what that feeling is like. I also know what it's like to try to compensate for my true desire. For me it was being an RN and NP school. They are NOT the same. Not even in the same league. I felt WORSE afterward because I knew I really wanted to be a physician and settled for the easier path.

The easier path is usually not the right one. How will you feel when you are 80 and look back on your life? How will you feel everyday when you go to work and finally realize you could have been a doctor? How will you feel when people ask you why you became an NP and you know the real reason was that you were afraid? Will you lie to them and yourself and say "I really like the NP model" or some other BS? I know how I felt. I also know all of my friends who settled feel.

Go for it!! Looking back I feel nothing but glad that I went to medical school. I actually enjoyed every day of medical school. I wasn't in a cave for 4 years. I had fun (I enjoyed learning). I'd rather spend another 2 years as a medical student than 10 years as an NP. Yes, it took time and yes I'm up to my eyeballs in debt but I get to wake up everyday knowing that I've received the best education I could and that I've done the most I can do for myself and I can give my patients the best care I can give. No regrets.

You've only got one shot at this life.

 

[Taurus]

Ultimately I see the "medical model" versus "nursing model" being judged by the courts. There will inevitably be a backlash by the public and the physician community when it is finally decided that NP's have too much autonomy. And when that is decided, it will be hard for the nurses to stand in front of the black robes and state that they practice anything outside of medicine. I mean tell me one treatment for any disease process treated by NP's that is treated ANY differently than the way a physician would treat it. There is no such thing as "advanced nursing". By definition, nursing is a subordinate role in medicine, though a very important one. It is oxymoronic to state that there is any form of advanced subordinate role. This would require supervision, which NP's are seeming to claim they do not need. Ultimately the physicians will not tolerate the turf trampelling and NP's will either be forced to practice the way PA's do in all states, or they will get the fight of their lives. Nursing lobby is powerful, but when all the physician groups lobby together for something, they have power too.

I agree that the courts will probably have to play an active role in the future sorting out these turf battles. Common sense and respect for roles won't. Last year, the anesthesiologists in Louisiana had to go to court to stop the CRNA's from doing pain management after the state's nursing board simply modified the CRNA scope. As the nurses try to invade medical areas, the physicians will fight back.

 

[prairiedog]

I agree that the courts will probably have to play an active role in the future sorting out these turf battles. Common sense and respect for roles won't. Last year, the anesthesiologists in Louisiana had to go to court to stop the CRNA's from doing pain management after the state's nursing board simply modified the CRNA scope. As the nurses try to invade medical areas, the physicians will fight back.

I was under the impression the insurance companies will sort out these turf battles! You did use the "B" word.

 

[Taurus]

I was under the impression the insurance companies will sort out these turf battles! You did use the "B" word.

Many variables are at play. Medical, legal, political, business, etc. That's reality. The nurses took their gloves off. Physicians will have to too.

 

[prairiedog]

Not everybody hates NPs, the vast majority of patients love their NPs

 

[deleted87716]

Not everybody hates NPs, the vast majority of patients love their NPs

I think it would be fair to say that patients who continue to go to NPs love their NPs. Kinda makes sense, though, doesn't it? 😉

For the same reason, everyone thinks their doctor is the "best doctor ever." If they didn't think that, they'd probably go somewhere else.

 

[lawguil]

Not everybody hates NPs, the vast majority of patients love their NPs

Just an interesting note: I work at a college and we just hired an NP in our health clinic who replaced a PA (may have replaced the PA physically, but not medically). Our head athletic trainer has stopped referring injured athletes to the clinic except when they can see the MD. This is only my second experience with an NP

1st referal - Grade III AC sprain....FNP evaluated as an RC tear.
2nd referal - ACL tear. FNP evaluated it as bursitis.
3rd referal - athlete who hit head and had post concussive symptoms. Evaluated by the FNP as unrelated to head trauma and felt that it might be related to a seizure disorder that she had recently read about in a journal. However, wrote a note returning the athlete to play.

Needless to say.................L.

The first NP I ever saw as a patient didn't know what Hodgkins Disease was!

Nice! L.

 

[thehelper]

Look, if you want to be doctor, go for it! You won't cut the coursework if you don't try. I know it seems intimidating but if you want it you can get it.

Trust me, I know what that feeling is like. I also know what it's like to try to compensate for my true desire. For me it was being an RN and NP school. They are NOT the same. Not even in the same league. I felt WORSE afterward because I knew I really wanted to be a physician and settled for the easier path.

The easier path is usually not the right one. How will you feel when you are 80 and look back on your life? How will you feel everyday when you go to work and finally realize you could have been a doctor? How will you feel when people ask you why you became an NP and you know the real reason was that you were afraid? Will you lie to them and yourself and say "I really like the NP model" or some other BS? I know how I felt. I also know all of my friends who settled feel.

Go for it!! Looking back I feel nothing but glad that I went to medical school. I actually enjoyed every day of medical school. I wasn't in a cave for 4 years. I had fun (I enjoyed learning). I'd rather spend another 2 years as a medical student than 10 years as an NP. Yes, it took time and yes I'm up to my eyeballs in debt but I get to wake up everyday knowing that I've received the best education I could and that I've done the most I can do for myself and I can give my patients the best care I can give. No regrets.

You've only got one shot at this life.

I dont know this person but i do know what he is talking about, do not let fear dictate what it is you want to truly be , you ay have trying times buti have come to understand that if it doesn't require my fullest then its probably not the best for me.
So i dont have any technical advise as far as what is and what isnt but rather just simple encouragement that you can do whatever you set your mind to becasue life is to short to fear something that you dont try it, live,learn, and always always never confuse motion with progress.
So make your own path and decide what you are going to do and let nothing discurage you.
Best of luck

 

[prairiedog]

Just an interesting note: I work at a college and we just hired an NP in our health clinic who replaced a PA (may have replaced the PA physically, but not medically). Our head athletic trainer has stopped referring injured athletes to the clinic except when they can see the MD. This is only my second experience with an NP

1st referal - Grade III AC sprain....FNP evaluated as an RC tear.
2nd referal - ACL tear. FNP evaluated it as bursitis.
3rd referal - athlete who hit head and had post concussive symptoms. Evaluated by the FNP as unrelated to head trauma and felt that it might be related to a seizure disorder that she had recently read about in a journal. However, wrote a note returning the athlete to play.

Needless to say.................L.

The first NP I ever saw as a patient didn't know what Hodgkins Disease was!

Nice! L.

Great examples! Your right all NPs are idiots, my fault. Needless to say looks like you fit well with the title of the thread. Can we follow the same logic with a MD, DPM, and a PA. Better yet what about a vocational counselor. I know of one vocational counselor who didn’t know the real difference between an ACT and SAT. Thus, all vocational counselors don’t know the difference between the ACT and SAT. Nice!

 

[Jack Daniel]

Just an interesting note: I work at a college and we just hired an NP in our health clinic who replaced a PA (may have replaced the PA physically, but not medically). Our head athletic trainer has stopped referring injured athletes to the clinic except when they can see the MD. This is only my second experience with an NP

1st referal - Grade III AC sprain....FNP evaluated as an RC tear.
2nd referal - ACL tear. FNP evaluated it as bursitis.
3rd referal - athlete who hit head and had post concussive symptoms. Evaluated by the FNP as unrelated to head trauma and felt that it might be related to a seizure disorder that she had recently read about in a journal. However, wrote a note returning the athlete to play.

Needless to say.................L.

The first NP I ever saw as a patient didn't know what Hodgkins Disease was!

Nice! L.

Great examples! Your right all NPs are idiots, my fault. Needless to say looks like you fit well with the title of the thread. Can we follow the same logic with a MD, DPM, and a PA. Better yet what about a vocational counselor. I know of one vocational counselor who didn't know the real difference between an ACT and SAT. Thus, all vocational counselors don't know the difference between the ACT and SAT. Nice!

I read lawguil's post much differently. It related anecdotal experience. Maybe the poster thinks that all NPs are idiots--but he didn't say that and I think it's a stretch to infer it. So knock the chip off your shoulder and start reading more carefully! 🙄

 

[chimichanga]

I read lawguil's post much differently. It related anecdotal experience. Maybe the poster thinks that all NPs are idiots--but he didn't say that and I think it's a stretch to infer it. So knock the chip off your shoulder and start reading more carefully! 🙄

The inference made was not such a grand leap, given the way midlevels are perceived on this board...
Though I reread the post, and it's clear that the TRAINER made the decision (about the one NP) after 3 missed diagnoses...Hopefully he won't "hate" on the remainder of NPs

Let's get real, however...This board is full of single anecdotal stories of "poor midlevel care" and then the inference is made by young, impressionable MS, who subsequently develop a chip toward midlevels, specifically NPs and CRNAs

Sounds like the clinic NP did terrible histories on 2 of these 3 pts, and just plain dropped the ball...

As a long time RN myself, I've had good and bad experiences w/ NPs, PAs, residents, attendings, etc...truthfully, I would prefer an MD/DO for my care overall...I don't think NPs in general, are prepared to practice independently, due to their lack of substantial "residencies"

Though hiring an NP/PA to see your ED fast track pts, and then actually seeing 90% of those behind the midlevel (the way many ED physician groups run their ERs) to make sure nothing was missed, is demeaning, and a waste of everyones' time...I certainly don't have all the answers

 

[Jack Daniel]

The inference made was not such a grand leap, given the way midlevels are perceived on this board...
Though I reread the post, and it's clear that the TRAINER made the decision (about the one NP) after 3 missed diagnoses...Hopefully he won't "hate" on the remainder of NPs

Let's get real, however...This board is full of single anecdotal stories of "poor midlevel care" and then the inference is made by young, impressionable MS, who subsequently develop a chip toward midlevels, specifically NPs and CRNAs

Sounds like the clinic NP did terrible histories on 2 of these 3 pts, and just plain dropped the ball...

As a long time RN myself, I've had good and bad experiences w/ NPs, PAs, residents, attendings, etc...truthfully, I would prefer an MD/DO for my care overall...I don't think NPs in general, are prepared to practice independently, due to their lack of substantial "residencies"

Though hiring an NP/PA to see your ED fast track pts, and then actually seeing 90% of those behind the midlevel (the way many ED physician groups run their ERs) to make sure nothing was missed, is demeaning, and a waste of everyones' time...I certainly don't have all the answers

Good post. Without sounding too philosophical, I think it's interesting to see how people get their information. No one seems to take the time to research an issue, consider the ins & outs, pros & cons, and then independently develop an informed opinion. Opinions are based on one or two experiences and/or perceptions gleaned from conversations and then are passed on as dogma. These are the same people who probably swear by EBM.

 

[prairiedog]

I read lawguil's post much differently. It related anecdotal experience. Maybe the poster thinks that all NPs are idiots--but he didn't say that and I think it's a stretch to infer it. So knock the chip off your shoulder and start reading more carefully! 🙄

Please read what was said, Lawguil used 4 examples of NP making the wrong diagnosis. Followed by "Needless to say.................L.

The first NP I ever saw as a patient didn't know what Hodgkins Disease was! "

I agree Lawguil didn't say NPs were idiots. So maybe if Lawguil could provide clarity, so we don't have infer. Lawguil, what do you think of NPs? Explain what you mean by "Needless to say.................L.
Thanks

 

[Bandit]

not one post that says "hey--noone HATES NPs.: ???????

I disagree with the OP premise. While their is wide spread bickering among students and newbies--anyone in medicine long enough understands every ones role.

These bickerings flair when someone puts out thier chest and beats "they are bettter." rediculous and petty.

I used to beat the drum about experience, length of didactic, clinical training medical this and nursing that. No time in my life for petty ****. Let it drop.

I was/am a long time ER PA. We exclusively hired PAs and never NPs. Our CEO couldnt justify hiring based on his perception of liability. My best friend was the worlds greatest ER nurse. He wanted to advance and I helped him get into NP school. He wil be terrific! He will, however get an inferior didactic training. But he will be a mid-level provider and will practice under his limitations---as I do.

What makes a great mid level? One who recognizes his/her limitations. These limits may very from topic to topic and environment from environment and person to person.

It is soooo easy to loose view of those lines and a long time provider becomes as dangerous as a new grad.

As for the competition..... another rediculous statment. PA/NP will never be a physician. As long as people are thinking straight and the lawyers still fight---people will seek out the highest in the field. MD/DO

 

[horsenurse25]

I myself can see NP's replacing GP's very easily. Every time I go to my GP I get referral to a specialist anyways.

If I have a minor complaint I go to a NP.
If I have a serious medical problem I go to a GP who then refers me to a specialist.

I can certainly envision a future of mainly NP's and specialists. There is a shortage of GPs anyways, so it makes sense to get the NP's to deal with minor, every day ailments and refer anything complicated on to those who are further trained to deal with it.

Besides, it will free up valuable GPs to see patients who need more medical expertise, rather than tying them up with more mundane health issues.

To the OP: I would go where your heart is. A NP is vastly different from a MD. Different philosophy, different training. A NP deals more in prevention and holistic care, a MD fixes things (or tries to). A NP usually has more time and interest in the whole patient. A MD is more interested in the hole in the patient.

 

[Therapist4Chnge]

Well, from what I read here, many people are extremely biased towards physician assistants. If you want the nursing perspective, since many NPs do not post here, go to www.allnurses.com. It has a lot of information. I would shadow some too, but you probably already know that.

Good luck with whatever you decide to do!

🙂

There is an implied bias there also....though I've been reading up on some of their forums over the past week or so, and I've learned a great deal about all of the sub-specialties, training, etc. It is definitely a great source of information, just make sure to put aside some time to sort through all of it.

As for the NP vs PA debate.....eh. It seems like most professionals (who have been out in the field awhile) can see the benefits of each position. I judge each professional individually....so whomever can provide me the best care is the one I want.

-t

ps. There is actually a LOOOOOOOONG thread over at allnurses about the NP vs PA debate. I read the first few pages to see the main arguements, and it rambles in places, but gives you a snapshot of the turf war.

 

[MedicineFoundMe]

Don't let this board influence you. Go out there and talk to NPs PAs MDs DOs and whoever else you want face to face. There is a lot of BS to wade through in here.

I am NP and take it from me... the training was gawd awful but if you have a MD to help you in the early years you'll be fine. You'll have to read and self teach a lot but you should do that in each path (you'll be forced to do that in the NP path). In the real world, there won't be much difference between PA and NP after a few years experience, which is why most of the job ads you'll see say NP/PA. If you want a chance at autonomy, go NP. If you want better medical training, go PA. If you want to be the captain, there's no choice but MD/DO. Make up your mind, because there are many sciences to take for med school, and that's a lot of work and effort if you don't have to have them. I took them all, and didn't need them to graduate after all. I'm sure you'll be a good healthcare provider no matter what you choose...

 

[fab4fan]

The inference made was not such a grand leap, given the way midlevels are perceived on this board...
Though I reread the post, and it's clear that the TRAINER made the decision (about the one NP) after 3 missed diagnoses...Hopefully he won't "hate" on the remainder of NPs

Let's get real, however...This board is full of single anecdotal stories of "poor midlevel care" and then the inference is made by young, impressionable MS, who subsequently develop a chip toward midlevels, specifically NPs and CRNAs

Sounds like the clinic NP did terrible histories on 2 of these 3 pts, and just plain dropped the ball...

As a long time RN myself, I've had good and bad experiences w/ NPs, PAs, residents, attendings, etc...truthfully, I would prefer an MD/DO for my care overall...I don't think NPs in general, are prepared to practice independently, due to their lack of substantial "residencies"

Though hiring an NP/PA to see your ED fast track pts, and then actually seeing 90% of those behind the midlevel (the way many ED physician groups run their ERs) to make sure nothing was missed, is demeaning, and a waste of everyones' time...I certainly don't have all the answers

I agree, chimi. What continues to confound me is the amount is venom here aimed at nurses, when in the real world, we (docs and nurses) manage to get along fairly well. Sometimes it's not so great, but nothing like what you see here. If it was, there wouldn't be any nurses. (There's a really wicked part of me that would like to see docs try to function for 24h without nurses, but I feel too sorry for the poor pts to really want that to happen.)

I also want to see a doctor if I'm sick. Why? I guess it boils down to having had bad experiences with NPs and PAs. Yes, I have had bad experiences with docs, too, but I have never had a good experience with an NP or a PA, and at this point, I'm not in to mood to give it another go. I have a new doc that I like and trust. End of discussion.

 

[Northerner]

Yeah, honestly the only reason people are taking shots at DNPs is because the Pod season opener isn't for another 5 weeks.

 

[chimichanga]

I agree, chimi. What continues to confound me is the amount is venom here aimed at nurses, when in the real world, we (docs and nurses) manage to get along fairly well. Sometimes it's not so great, but nothing like what you see here...

Confound on:

...Honestly, if it's going to change, it has to change with the nurses first. For every jerk med student who's condescending or mean to a nurse, there's 10 nurses doing it to undeserving med students.

http://forums.studentdoctor.net/showpost.php?p=4991982&postcount=13

I guess it's all our fault

 

[Dr_Feelgood]

Yeah, honestly the only reason people are taking shots at DNPs is because the Pod season opener isn't for another 5 weeks.

 

[jonwill]

Yeah, honestly the only reason people are taking shots at DNPs is because the Pod season opener isn't for another 5 weeks.

It's always open season on our forum!

 

[corpsmanUP]

Don't let this board influence you. Go out there and talk to NPs PAs MDs DOs and whoever else you want face to face. There is a lot of BS to wade through in here.

I am NP and take it from me... the training was gawd awful but if you have a MD to help you in the early years you'll be fine. You'll have to read and self teach a lot but you should do that in each path (you'll be forced to do that in the NP path). In the real world, there won't be much difference between PA and NP after a few years experience, which is why most of the job ads you'll see say NP/PA. If you want a chance at autonomy, go NP. If you want better medical training, go PA. If you want to be the captain, there's no choice but MD/DO. Make up your mind, because there are many sciences to take for med school, and that's a lot of work and effort if you don't have to have them. I took them all, and didn't need them to graduate after all. I'm sure you'll be a good healthcare provider no matter what you choose...

Extremely good post, and thanks for the honesty. Before I was a physician, when I was a practicing PA, I would talk with NP's I worked with routinely. Unfortunately I never found one that had a balanced education and what I would call excellent clinical knowledge across the board. Peds NP's were definitely better than Peds PA's, as were Women's health NP's. But, family NP's are the ones I worry about. They get terrible orthopedic and musculoskeletal training, and terrible training in general. Every NP in FM who I have ever talked with did about 1/5 as many clinical hours as myself in the 2nd year. They worked as RN's on floors getting paid the rest of the time. Their argument was that their previous experience allowed them to learn equally as much as PA's with less hours.

Pardon me, but if you worked in the past in ANY nursing field as an RN, it does not make you more capable of learning autonomous MEDICAL care of the typical FM patient. PA's are trained in the medical model, and spend thousands of clinical hours providing care with physicians in their clinical year. This is what makes a PA more qualified than an NP, and why I will never hire an NP. Sure, an NP can read and catch up, but the fact that they are not required to do so and can continue just getting by doing the wrong thing is freaking scary.

Being a prior midlevel myself, I will happily donate free hours of depositions and congressional hearing time when this debate reaches the highest levels. The PA's will have a voice with me and the NP's will.....lets just say I won't have kind things to say about their education.

I just don't get it, why would NP training not simply get upgraded to increase the credibility of it? I mean even the NP I quote above admits it is total crap! I would have no heartburn and might even tolerate the independence idea IF the training was there to back it up. I might even be willing to admit that there is a role for independent midlevels in GP if a curriculum on the NP side could be developed that was as good or better than the accredited PA model.

 

[core0]

I just don't get it, why would NP training not simply get upgraded to increase the credibility of it? I mean even the NP I quote above admits it is total crap! I would have no heartburn and might even tolerate the independence idea IF the training was there to back it up. I might even be willing to admit that there is a role for independent midlevels in GP if a curriculum on the NP side could be developed that was as good or better than the accredited PA model.

I think the real answer to your question is quite interesting. The original PA and NP programs were very similar in structure. The PA program was a year of full time didactic work followed by 12 months of clincals. The curriculum was not the same as it is now (maintenance of electromechanical devices was a big part for example) but the concept was the same. The original NP program was 9 months of full time didactic work followed by 15 months of clinical work. So both programs were about 2 years of full time work.

In the 1970's the PA program introduced the first masters and bachelors programs but kept the clinical and didactic time the same. At the same time in an effort to expand accessability to post grad nursing education the clinical and didactic time started to shrink. The effort was to allow the RN to work full time while in school. This trend has continued and results in the current situation.

Two other factors have made this situation worse. The original NP's had an extensive amount of time as RN's (the first class at CU had an average of more than 15 years). The experience component has been decreasing over the years (although the magnitude is difficult to determine). Along with this there are a growing number of direct entry NP programs (students without an RN enter and receive thier BSN after 1-2 years and NP after three years (part time). So you have a situation where RN's have less of the experience which is supposed to be the cornerstone of the NP practice.

The second phenomenen which is less recognized is the disappearance of the office nurse. Most RN's in the office have been replaced by MA's. When you look at the nursing background for correlation to NP practice there are some that are easy to figure out OB > WHNP/CNMW Peds > PNP ICU>ACNP. Some of the others are less obvious. Is a med/surg nurse the precursor for an FNP? or ANP? In the past maybe, when less ill patients were routinely admitted to the hospital. Now most patients in the hospital are very ill. The experience would be most applicable to ACNP. An ortho RN might have ortho experience but it would not be in diagnosis or management but post op care.

The days when people get diagnosed with things in the hospital are for the most part gone. Most hospital admissions are for acute exacerbations of chronic conditions or acute conditions where hospitalization is needed. I work in a specialty and while we do more diagnostic work ups than most, it is mostly in relationship to some other illness that got them hospitalized.

This comes back to what NP's can do to improve education. Thier answer is the nursing doctorate. If you examine the programs they add 1000 hours of clinical time along with extra course work in pathophysiology, pharmacology and diagnosis/management. While this will put NP's a little shy of PA training it will become more equivalent. While I may disagree wether this rates a doctorate, I do think this will help the profession with many of the problems that you have identified.

What they have not examined is what this will do to enrollment. I think that faced with the prospect of 2 years of full time work or 6 years of part time work, that this will result in a dramatic reduction in NP students. Some programs such as CRNA already use this model, but most don't.

The final piece of this puzzle is scope of practice. In the PA world, our scope of practice is dependent on our supervising physician. In the NP world the scope of practice is dependent on thier education and clinical experience as indepedent practitioners. As NP's expanded they moved into areas where they had no formal NP education such as cardiology or orthopedics. While they may have nursing experience they had no formal didactic training in cardiology beyond what they recieved in school. There are also many FNP's working in inpatient settings despite most or all of their training in outpatient primary care. The advent of the ACNP solved this somewhat and most of our hospitals are requiring this for inpatient work. The DNP will allow the APN to specialize somewhat in that 1000 hours.

Long post, complex issue.

David Carpenter, PA-C

 

[hunnybee24]

To Therapist4Change:

I didn't state that there wasn't a bias there as well. I just wanted to give you information so you can decide for yourself whats best. I hope you aren't forming the majority of your opinions about your future career based on forum posts.

There is an implied bias there also....though I've been reading up on some of their forums over the past week or so, and I've learned a great deal about all of the sub-specialties, training, etc. It is definitely a great source of information, just make sure to put aside some time to sort through all of it.

As for the NP vs PA debate.....eh. It seems like most professionals (who have been out in the field awhile) can see the benefits of each position. I judge each professional individually....so whomever can provide me the best care is the one I want.

-t

ps. There is actually a LOOOOOOOONG thread over at allnurses about the NP vs PA debate. I read the first few pages to see the main arguements, and it rambles in places, but gives you a snapshot of the turf war.

 

[corpsmanUP]

The biggest problem with NP independent practice is that their patients have no safety net for what they "don't know that they don't know". As a PA, I always had the option to walk down the hall and talk to my doc, and/or call him on the phone if he was not in the office. I also was rather well respected because my credibility ran on the coattail of my doc. When NP's start opening primary care offices around the country (I pray they don't), they will initially wow their patients like most midlevels with superior bedside manner and compassion. That is the cornerstone of the NP profession, and somewhat the PA profession. But patients almost always equate bedside manner with knowledge and ability. I was universally better liked in my practice than my physician colleagues because I knew I had to go the extra mile to win my patient's trust. But looking back, I truly didn't know what I did not know! NP's always talk about outcome studies. There are no true outcome studies other than patient satisfaction surveys and other non evidence based crap. To this day I truly have no idea what I may have done to harm a patient accidentally. But almost weekly in medical school and residency I have come across rather crucial pieces of information that ring a bell in my head, and remind me of something I should not have done in my previous profession. You just cannot substitute the education a physician gets in any field, including primary care fields.

Just tell me how the NP curriculum can compare to 4 years of medical school and a minimum of 3 years in residency. And I would venture to say that each year of residency would be more useful than an entire NP curriculum. The basic science education of NP's is so laughable that I would challenge the AMA to allow them to sit for the USMLE Steps. If ANY NP could pass the series of exams, I would argue to allow them to be independent and even call themself doctor. It's not about titles at all or turf wars, but about true medical education and ways to assure than anyone independently has surpassed a certain standard.

I agree that in primary care, there needs to be something done to create more primary care providers in rural areas and underserved places in general. I obviously believe that the RN community is an incredible place to harvest such talented people. I just believe though that this education should be done through medical schools and not nursing schools. How can a nurse teach another nurse about the medical model without a medical degree? Doctors need to associate with NP programs and NP programs need to become more accountable for their education. We could benefit from each other's skillsets and make a true Doctoral level primary care provider and do away with all PA and NP titles and degrees.

I believe you grandfather all current PA/NP types by making them take an exam bridging them to a doctorate degree. Then I believe you create within medical schools a curriculum for primary care that has 2 entry points. One would be the routine pre-PA/preMD route students, and the other those with healthcare experience. Those that agree in advance to pursue primary care would take a completely different route to becoming this new doctorate degree, called the DPC (Doctor of Primary Care). DPC education would be 2-3 years total, followed by a 1-2 year residency in a respective primary care field to include family medicine, psychiatry, or pediatrics. Any other field would require the traditional 4 year route plus residency.

DPC's would be independent, and would make as much money as any other primary care physician previously. This would tempt the NP wannabes into doing it the right way, and would eliminate worthless nursing model education. I think something like this could really work and it would probably cure the shortage of primary care docs. I venture to say it would take the practicing PA or NP about 6 months of intensive studying to make the bridge.

No more PA's, no more NP's, and all medical providers coming from US medical schools where we all know the best education occurs.

 

[Therapist4Chnge]

To Therapist4Change:

I didn't state that there wasn't a bias there as well. I just wanted to give you information so you can decide for yourself whats best. I hope you aren't forming the majority of your opinions about your future career based on forum posts.

I didn't mean for it to come off like I was needling your post. I definitely encourage people to do as much research as possible, and go in with your eyes open. I'd be a very poor business person if I only considered opinions of others and failed to do my own research (outside of forums, etc).

Cheers.

-t

 

[MedicineFoundMe]

The biggest problem with NP independent practice is that their patients have no safety net for what they "don't know that they don't know". As a PA, I always had the option to walk down the hall and talk to my doc, and/or call him on the phone if he was not in the office. I also was rather well respected because my credibility ran on the coattail of my doc. When NP's start opening primary care offices around the country (I pray they don't), they will initially wow their patients like most midlevels with superior bedside manner and compassion. That is the cornerstone of the NP profession, and somewhat the PA profession. But patients almost always equate bedside manner with knowledge and ability. I was universally better liked in my practice than my physician colleagues because I knew I had to go the extra mile to win my patient's trust. But looking back, I truly didn't know what I did not know! NP's always talk about outcome studies. There are no true outcome studies other than patient satisfaction surveys and other non evidence based crap. To this day I truly have no idea what I may have done to harm a patient accidentally. But almost weekly in medical school and residency I have come across rather crucial pieces of information that ring a bell in my head, and remind me of something I should not have done in my previous profession. You just cannot substitute the education a physician gets in any field, including primary care fields.

Just tell me how the NP curriculum can compare to 4 years of medical school and a minimum of 3 years in residency. And I would venture to say that each year of residency would be more useful than an entire NP curriculum. The basic science education of NP's is so laughable that I would challenge the AMA to allow them to sit for the USMLE Steps. If ANY NP could pass the series of exams, I would argue to allow them to be independent and even call themself doctor. It's not about titles at all or turf wars, but about true medical education and ways to assure than anyone independently has surpassed a certain standard.

I agree that in primary care, there needs to be something done to create more primary care providers in rural areas and underserved places in general. I obviously believe that the RN community is an incredible place to harvest such talented people. I just believe though that this education should be done through medical schools and not nursing schools. How can a nurse teach another nurse about the medical model without a medical degree? Doctors need to associate with NP programs and NP programs need to become more accountable for their education. We could benefit from each other's skillsets and make a true Doctoral level primary care provider and do away with all PA and NP titles and degrees.

I believe you grandfather all current PA/NP types by making them take an exam bridging them to a doctorate degree. Then I believe you create within medical schools a curriculum for primary care that has 2 entry points. One would be the routine pre-PA/preMD route students, and the other those with healthcare experience. Those that agree in advance to pursue primary care would take a completely different route to becoming this new doctorate degree, called the DPC (Doctor of Primary Care). DPC education would be 2-3 years total, followed by a 1-2 year residency in a respective primary care field to include family medicine, psychiatry, or pediatrics. Any other field would require the traditional 4 year route plus residency.

DPC's would be independent, and would make as much money as any other primary care physician previously. This would tempt the NP wannabes into doing it the right way, and would eliminate worthless nursing model education. I think something like this could really work and it would probably cure the shortage of primary care docs. I venture to say it would take the practicing PA or NP about 6 months of intensive studying to make the bridge.

No more PA's, no more NP's, and all medical providers coming from US medical schools where we all know the best education occurs.

That's the smartest approach to this whirlwind of BS I've ever heard. I couldn't agree more. I actually talked my school into letting me in with no RN experience because I told them RN experience is irrelevant when you are looking over a doctor's shoulder and saying, "yeah, that's what I thought too". It's a whole different way of thinking... almost like saying mopping the floors in the hospital prepares you for the CFO position because you overheard a few numbers at a meeting or two. Unless the RN goes into this experience with the knowledge that they have to learn how to be the person writing the orders and figuring out what's wrong and how to manage it, there is no benefit. The only reason I'm so far ahead of my peers in similar situation is I realized that early and while the NP teachers were talking I read medical journals (or found some other way to ignore them, such as Texas Hold 'Em) and I took that approach in my RN experience and made it very clear to my buddy docs I worked with in the ER who took me under their wing almost like a resident and taught me for the two years I spent there. I read medical books every day. Plus I'm really really really smrt. I mean smart. I'd like to take your USMLE...

 

[Tired]

Let's get real, however...This board is full of single anecdotal stories of "poor midlevel care" and then the inference is made by young, impressionable MS, who subsequently develop a chip toward midlevels, specifically NPs and CRNAs

...

As a long time RN myself, I've had good and bad experiences w/ NPs, PAs, residents, attendings, etc...truthfully, I would prefer an MD/DO for my care overall...I don't think NPs in general, are prepared to practice independently, due to their lack of substantial "residencies"

Thanks for linking to one of my posts. Also nice to see that you continue to dismiss others' anecdotal experiences with . . . your anecdotal experience.

I won't post here again, just wanted to check it out.

 

[fab4fan]

That's the smartest approach to this whirlwind of BS I've ever heard. I couldn't agree more. I actually talked my school into letting me in with no RN experience because I told them RN experience is irrelevant when you are looking over a doctor's shoulder and saying, "yeah, that's what I thought too". It's a whole different way of thinking... almost like saying mopping the floors in the hospital prepares you for the CFO position because you overheard a few numbers at a meeting or two. Unless the RN goes into this experience with the knowledge that they have to learn how to be the person writing the orders and figuring out what's wrong and how to manage it, there is no benefit. The only reason I'm so far ahead of my peers in similar situation is I realized that early and while the NP teachers were talking I read medical journals (or found some other way to ignore them, such as Texas Hold 'Em) and I took that approach in my RN experience and made it very clear to my buddy docs I worked with in the ER who took me under their wing almost like a resident and taught me for the two years I spent there. I read medical books every day. Plus I'm really really really smrt. I mean smart. I'd like to take your USMLE...

Yeah. Thanks for the insult, pal. Just because I have worked for many years as a nurse does not mean I stand next to a doc, nodding my head in agreement with everything he says. Believe it or not, bedside nurses are capable of independent thought. I've even on occasion been bold enough to state my case for why I thought something else was going on with the pt. I would never say, "Yeah, that's what I thought too" if I indeed had not thought the same thing. Even if I did agree, I probably wouldn't need to say it.

It must have been a real treat for your fellow nurses to work with you. I'm sure you reminded them every chance you could that you were just slumming until you could move on to bigger and better.

I have no problem with nurses who choose to go into advanced practice or med school. I have a major problem with those who do who dis the nurses who remain at the bedside. In case you've forgotten, we're the people who are there 24/7 monitoring pts, assessing changes in their condition and taking appropriate action before a small problem becomes a big one. You know, not just people who blindly follow orders, fluff pillows and hold hands. We do, on occasion, think.

You may be brilliant, for all we know, but it's too bad that for all your book smarts you didn't learn a simple truth: A skilled nurse is worth his/her weight in gold. Sadder still that you had to belittle the very people you're going to be counting on to help you do your job in the future.

At least you don't need to work on any self-confidence issues.

 

[Jejton]

This has been discussed many times. There is a large difference in the philosophy and education between the two. PAs generally work with physicians; advanced practice nurses are trying to replace physicians (“separate but equal”).

I dont think this is really true. All the NP's I have come across have been working alongside a doctor ( at least in oncology ) and they have been pretty indespensable. I dont think the doctors had any problems with the arrangments since the NP's werent forced on them. I think that NP's can fill a niche running clinics in rural areas that are underserved by doctors, as well as assisting in overburdened ER's. In these cases I dont see how they are a threat to doctors.

 

[core0]

I dont think this is really true. All the NP's I have come across have been working alongside a doctor ( at least in oncology ) and they have been pretty indespensable. I dont think the doctors had any problems with the arrangments since the NP's werent forced on them. I think that NP's can fill a niche running clinics in rural areas that are underserved by doctors, as well as assisting in overburdened ER's. In these cases I dont see how they are a threat to doctors.

It depends on who you listen to. If you listent to the ANA or the nursing educators then yes they intend to replace the physicians. If you listen to the people actually working in the field then no they want a collaborative model working with physicians. In theory since there are many more NP's in practice this is the voice that should be heard. But the ANA controls the message so now you get "is your doctor an NP".

David Carpenter, PA-C

 

[deleted87716]

Meanwhile, most of the people being called "nurse" in hospitals and doctors' offices these days are actually nursing assistants or medical assistants...or people with no clinical training whatsoever. IMO, nursing is losing sight of its roots, and seems hell-bent on proving the Peter Principle.

Kudos to all of you who choose to be nurses, first and foremost. We need you.

 

[Dr_Feelgood]

Meanwhile, most of the people being called "nurse" in hospitals and doctors' offices these days are actually nursing assistants or medical assistants...or people with no clinical training whatsoever. IMO, nursing is losing sight of its roots, and seems hell-bent on proving the Peter Principle.

Kudos to all of you who choose to be nurses, first and foremost. We need you.

👍

The nursing leadership seems not to care about nursing anymore. It is as if it is below them, a CMA or a LNA can do that. This sad but true.

 

[MedicineFoundMe]

Yeah. Thanks for the insult, pal. Just because I have worked for many years as a nurse does not mean I stand next to a doc, nodding my head in agreement with everything he says. Believe it or not, bedside nurses are capable of independent thought. I've even on occasion been bold enough to state my case for why I thought something else was going on with the pt. I would never say, "Yeah, that's what I thought too" if I indeed had not thought the same thing. Even then, I probably wouldn't say it.

It must have been a real treat for your fellow nurses to work with you. I'm sure you reminded them every chance you could that you were just slumming until you could move on to bigger and better.

I have no problem with nurses who choose to go into advanced practice or med school. I have a major problem with those who do who dis the nurses who remain at the bedside. In case you've forgotten, we're the people who are there 24/7 monitoring pts, assessing changes in their condition and taking appropriate action before a small problem becomes a big one. You know, not just people who blindly follow orders, fluff pillows and hold hands. We do, on occasion, think.

You may be brilliant, for all we know, but it's too bad that for all your book smarts you didn't learn a simple truth: A skilled nurse is worth his/her weight in gold. Sadder still that you had to belittle the very people you're going to be counting on to help you do your job in the future.

At least you don't need to work on any self-confidence issues.

I don't have a problem with nurses in general. I've worked with brilliant nurses and one of my best friends is a RN who is smarter than any NP I know. But I've also come across MANY nurses that argue that their inpatient experience makes them better at outpatient practice, and for the most part that's just not true. THOSE RNs are the ones I intend to insult because if they're not embarassed they won't ever change their thinking.

I came across as insulting to current RNs and I did not intend that... my apologies. I know very much the importance of RNs in the hospital as I too depend on them to monitor patients I have put in the hospital. It's the why I as a NP am putting patients in the hospital that I have a problem with. I generally have no business managing a patient that is sick enough to be in the hospital.